ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
- A. Redness at the catheter insertion site
- B. Report of headache and stiff neck
- C. Temperature of 100.1 F (37.8 C)
- D. Pain rating of 8 on a scale of 0 to 10
Correct answer: Report of headache and stiff neck
Rationale:
2. What is the initial intervention for a patient experiencing an allergic reaction?
- A. Administer antihistamines
- B. Administer corticosteroids
- C. Administer oxygen
- D. Administer IV fluids
Correct answer: A
Rationale: The correct answer is to administer antihistamines as the initial intervention for a patient experiencing an allergic reaction. Antihistamines work to block the effects of histamine, a substance released during an allergic reaction, helping to relieve symptoms such as itching, swelling, and hives. Corticosteroids (Choice B) are sometimes used in severe cases to reduce inflammation, but they are not the first-line treatment for an allergic reaction. Administering oxygen (Choice C) may be necessary if the patient is having difficulty breathing, but it is not the first intervention. IV fluids (Choice D) are typically given for conditions like dehydration or shock, not as the primary intervention for an allergic reaction.
3. Which of the following statements is not true about selective mutism?
- A. The disturbance is often marked by high social anxiety
- B. It can be diagnosed alongside social anxiety disorder
- C. The person is capable of speaking in some situations
- D. It may lead to academic impairment
Correct answer: B
Rationale: Selective mutism can coexist with social anxiety disorder. The correct answer is B because it is incorrect to say that selective mutism cannot be diagnosed alongside social anxiety disorder. Statement A is true as selective mutism is often associated with high social anxiety. Statement C is true as individuals with selective mutism can speak in some situations. Statement D is true as selective mutism may lead to academic impairment due to difficulties in communication.
4. A nurse is assessing a client who is experiencing a panic attack. Which of the following findings should the nurse expect?
- A. Bradycardia.
- B. Hypotension.
- C. Chest pain.
- D. Dilated pupils.
Correct answer: D
Rationale: During a panic attack, the sympathetic nervous system is activated, leading to physiological responses such as dilated pupils. Bradycardia (slow heart rate) and hypotension (low blood pressure) are not typically associated with panic attacks. While chest pain can occur during a panic attack due to rapid breathing and muscle tension, dilated pupils are a more specific finding related to sympathetic activation in this context.
5. Which structure serves as the major chemoreceptor of the heart?
- A. Carotid body
- B. Aortic body
- C. Vagus nerve
- D. SA node
Correct answer: A
Rationale: The correct answer is A, the carotid body. The carotid body is the major chemoreceptor of the heart responsible for detecting changes in blood oxygen, carbon dioxide, and pH levels. This specialized structure helps regulate the cardiovascular system's response to maintain appropriate oxygen levels in the blood. Choices B, C, and D are incorrect as they are not directly involved in chemoreception in the heart. The aortic body is primarily involved in blood pressure regulation, the vagus nerve is a cranial nerve responsible for parasympathetic innervation, and the SA node is known as the heart's natural pacemaker.
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